Exploring Perspectives on Feasibility, Challenges, and Support Needs for Chlorhexidine Gluconate (CHG) Bathing in the Outpatient Setting for Hematopoietic Cell Transplant Recipients: A Qualitative Study

Abstract

Background:

Chlorhexidine gluconate (CHG) bathing is recommended for infection prevention in hematopoietic cell transplantation (HCT) patients. As more centers transition HCT care to outpatient settings, understanding patients’ perceptions of CHG bathing feasibility, support needs, and home-based barriers in the home environment is critical to promoting adherence.

Objective:

This study explores HCT patient perceptions regarding feasibility of CHG bathing in the outpatient setting to identify barriers and support needs.

Study Design:

We conducted a qualitative descriptive study with 14 HCT (mean 51±16 years) recipients recruited from an inpatient transplant unit. Semi-structured interviews were conducted via phone, video, or in person within three months post-discharge. A rapid qualitative analysis approach was used to identify key subthemes related to feasibility, challenges, and needed support.

Results:

Participants supported the feasibility of CHG bathing in the outpatient setting and were supportive of its continued use post-discharge. Participants sited potential challenges including lack of motivation, home management difficulties, and administration concerns. Participants identified the need for structured reminders and accountability, caregiver support, and clinical follow-up. The importance of education emerged as a salient theme. Suggestions for improving adherence included integrating CHG bathing into daily routines and enhancing patient education.

Conclusion:

While CHG bathing in the outpatient setting is feasible, targeted interventions, such as education, reminders, and caregiver involvement may improve adherence and optimize infection prevention. Findings from this study can inform the application of CHG in the outpatient setting and development of innovative, patient-driven strategies to improve CHG adherence. Future efforts should focus on addressing identified barriers to support successful outpatient implementation.

Introduction

Hematopoietic stem cell transplantation (HCT) is a potentially curative treatment for a wide range of malignant and nonmalignant hematologic disorders (1). However, patients undergoing HCT face significant infection risk, with 13–55% of HCT recipients experiencing at least one bloodstream infection (BSI) (2–6). Increased risk for BSI can be attributed to several factors including prolonged immunosuppression (7), extended periods of neutropenia (8), and delayed post-HCT immune reconstitution (9,10). Bloodstream infections pose numerous health concerns and are associated with worse HCT-related outcomes including acute graft versus host disease (11), longer lengths of stay (12), hospital readmission (13,14), and mortality (12,15). Risk for BSI in HCT can be reduced through the implementation of standard infection control strategies (16).

Chlorhexidine gluconate (CHG) is a widely used antiseptic that has demonstrated effectiveness in lowering rates of healthcare-associated infections (HAIs) of multidrug-resistant organisms (MDROs), including central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated pneumonia (VAP), and surgical site infections (SSIs) (17,18). It exerts its effects by binding to negatively charged components on the cell walls of bacteria, which leads to increased permeability, leakage of intracellular contents, and disruption of metabolic processes (19,20). At higher concentrations (≥2%) and sustained exposure, it further reduces membrane integrity, ultimately leading to bacterial cell death (19–21). It also provides residual antimicrobial activity for up to 24 hours, supporting once-daily use (22).

Although it is safe and effective for lowering infection risk specifically in HCT patients (23), adherence is a key factor; we previously found significantly reduced BSI incidence (8%) among patients with high daily CHG adherence (>75% adherence) compared to 15% and 30% incidence for those with low/moderate adherence or no CHG, respectively (23). Barriers to adherence included difficulty applying CHG wipes to prescribed areas, post-application ‘stickiness,’ cold temperature, and disruption of usual bathing routines (20,21).

CHG bathing is primarily implemented during the inpatient stay and less is known regarding its application in the outpatient setting. Gaining evidence on CHG adoption outside the hospital is relevant as recent evidence supports the growing shift of HCT from the inpatient to outpatient setting. In this model, patients are discharged home immediately following pre-HCT conditioning and stem cell infusion, rather than spending the initial recovery period in the hospital (24). This shift may lead to better quality of life (24) and significant cost benefits, with an estimated 33.42% and 19.27% cost reduction for autologous and allogeneic HCT, respectively (25). Previous studies highlight challenges HCT patients face in outpatient care, including adherence to immunosuppressant medication (26) and return to baseline functional status after HCT (27). We recently reported on HCT recipients’ perceived facilitators, barriers, and education/knowledge related to CHG bathing while in the in-patient unit (28). Less is known regarding HCT patients’ needs and barriers to the implementation of infection control strategies, such as CHG bathing while recovering at home. Therefore, this study expands on our previously published results by focusing on HCT recipients’ perspectives regarding the use of CHG bathing in the outpatient setting, with a specific focus on feasibility, challenges, and support needed. This research aims to inform strategies for optimizing CHG implementation during outpatient care by identifying potential factors that may influence adherence.

Methods

HCT recipients were recruited from the Duke Adult Blood and Marrow Transplant Inpatient Unit during their inpatient stay between April 2022 and April 2023. Patients were eligible to participate if they were 1) currently in the hospital following HCT or had been discharged within the past three months; and 2) had been prescribed daily CHG treatment. Although patients were recruited in the unit, they could choose to complete the interview during their inpatient stay or later within three months post discharge. The study protocol was approved by the Duke University’s Institutional Review Board (Protocol # Pro00093701). Verbal consent was obtained from participants, as the study posed minimal risk.

This study used a qualitative description approach with the primary aim of exploring patients’ perceived facilitators, barriers, and education/knowledge of CHG bathing. Results from HCT patients’ perceived facilitators, barriers, and education/knowledge related to CHG bathing in the inpatient setting have been published previously (28). This analysis focuses on the secondary study aim of exploring patients’ perceptions of using CHG treatment in the outpatient setting. Patients who were interested in participating were scheduled for an interview that took place via telephone, video conference, or in person. Semi-structured interviews were conducted by one or two female members of the research team (ALA and LJF). These researchers had previous research experience in cancer and qualitative methods, and they were not familiar with the participants prior to the study. An interview guide was used with questions related to participants’ perceptions regarding conducting CHG bathing at home, perceived challenges and needed support, and suggestions for implementation (questions are shown in Table 1). Interviews were audio recorded.

Table 1:

Interview Questions

1.	We are planning to have people who get a bone marrow transplant treat themselves at home using the CHG wipes. What are your thoughts about doing this at home?
2.	What support would someone need to do this at home?
3.	How would that work for you and your family/caregiver?
4.	Using the CHG wipes at home may be different than doing it here in the BMT unit. What are some things that would make treatment with the wipes at home more challenging?
5.	Do you have any suggestions for ways that other patients may be able to make this a daily habit or tie it into other activities they do throughout the day?
6.	The recommendation would be to use the wipes on a daily basis. What are your thoughts about this?
7.	What else is important for us to know about BMT patients using or self-administering the CHG treatment at home?

The sample size was guided by the concept of information power, which posits that the more relevant information participants hold for the study aims, the fewer participants are needed (29). Given the specificity of our research question, the relative homogeneity of the sample, and the quality of the interview data, we determined that 14 participants provided sufficient information power to address the study objectives.

Data Analysis

A rapid qualitative analysis approach (30–32) was used to analyze interviews. This method employs a reduced, but rigorous, analysis where interviews were coded directly from the recordings rather than being transcribed. A deductive template was created in Microsoft^® Excel and used to organize the analysis and summarize each interview, without the use of transcription of qualitative software. The template was organized with a dedicated column for each interview question, allowing for direct entry of participants’ responses and quotes. so that each interview question was displayed at the top of the column. The analysis was conducted by two qualitative analysts (ALA and LJF): ALA used the template to code and summarize the first two interviews. The codes and summaries were reviewed by a second analyst (LJF). Following the review, the analysts met to generate a finalized revised template, and the remaining interviews were analyzed by ALA. Once the first round of coding and summaries was complete for the first 10 patients, the two qualitative analysts reviewed interview quality and codes to assess patient responses, content richness, and saturation. Following this meeting, enrollment, interviews, and coding continued and the analysts met again to review the data after four more interviews. Based on the homogeneity of the sample and the quality of the participant responses, codes, and themes, we determined that the 14 participants provided sufficient information to address the study objectives and thus completed participant enrollment.

Results

Fourteen patients participated in semi-structured interviews during the early post-transplant recovery period. Most participants were middle-aged, and 64% were female. Interviews were predominantly conducted in person, with a small number conducted via Zoom or phone. Demographic and clinical characteristics are summarized in Table 2. Average time of CHG use during participants’ in-patient stay was 14 ± 7 days. Five participants also reported prior CHG use, all within the past two years, during prior chemotherapy treatment or hospitalization.

Table 2.

Participant Characteristics (n=14)

Characteristic	Value (Mean ± SD or n (%))
Age (years)	51 ± 16
Gender
Male	5 (36%)
Female	9 (64%)
Time post HCT (days)	11 ± 9
Time of CHG use during inpatient stay (days)	14 ± 7
Participants with prior CHG experience	5 (35.7%)
Interview modality
In-person	12 (86%)
Video Conference	1 (7%)
Telephone	1 (7%)

CHG: Chlorhexidine Gluconate; HCT: Hematopoietic Cell Transplantation

Interview questions were organized around three primary themes: feasibility of outpatient CHG use, challenges to sustained adherence, and support needs. Inductive analysis yielded specific subthemes within each theme. Subthemes and illustrative quotes are provided in Table 3.

Table 3.

Themes, Subthemes, and Representative Quotes Related to Outpatient CHG Adherence

Theme	Subtheme	Representative Quote
Feasibility	N/A	“I almost think it would be more beneficial for outpatient to do it because they are exposed to so much more than a patient inpatient in the hospital…Doing the CHG wipes at home would only increase the precautions you are taking and make a patient safer.” (P04)
Challenges to Sustained Adherence	Motivation decline	“…it would be more challenging at home because no one is going to remind you…making yourself do it is a challenge.” (P09)
	Home management challenges	“I would just have to make arrangements before I take a bath---Who is going to be able to come over and wipe me down? And of course, it would be a challenge to keep the wipes warm unless they were to give me a warmer or something.” (P01)
	Self-administration challenges	“Just someone to help the back area mostly…if the person is still having a lot of issues, they might need more help from someone at home.” (P12)
Support Needs	Reminders & accountability	“…on the days they do not feel like doing it themselves, they’ll have somebody who knows how to do it too.” (P14)
	Caregiver involvement	“…I think that’s the big key is having that caregiver, having someone forceful enough, loving, but forceful enough to say this needs to be done. It’s for your own good, your own safety, and you need to make sure to do it every day.” (P04)
	Clinical follow-up	“follow-up, nursing calls, maybe weekly—‘how is everything going with your CHG wipes, are you getting to do it or any signs of infection’---things like that.” (P11)

Feasibility

Most participants expressed that using the CHG wipes in the outpatient setting was feasible and beneficial for infection prevention. Several noted that CHG wipes served as a helpful alternative to showering during the early post-discharge when they felt physically weak. For example, P03 shared, “it makes everything easier until you get your strength back,” and P07 added, “I think it’s a good idea, especially if you’re in outpatient. It’s an easy way to get a bath.”

In addition to practicality, several participants described outpatient CHG bathing as beneficial for infection prevention. These responses reflect participants’ beliefs about why CHG is important, which reflected their inclination to use them and contribute to feasibility. P04 emphasized, “I would think the chances of infection would be higher [at home]. Because of that, you need to take more precautions. Doing the CHG wipes at home would only increase the precautions you are taking and make a patient safer.” Similarly, P12 stated, “If it is worth the time it takes to do it, which is not that long, I guess it is worth it, if it helps with infection and bacteria.”

Challenges to Sustained Adherence

Participants identified several challenges they anticipated encountering when performing CHG bathing at home, including motivation decline, challenges with home management, and challenges with self-administration.

Motivation Decline

Although participants recognized the importance of CHG adherence, many anticipated a decline in motivation once discharged. Participants cited reduced oversight, fatigue, and competing priorities as barriers to consistent use. P12 admitted that she would, “…get a little tired of it after a few weeks.” Similarly, P09 echoed,“…it would be more challenging at home because no one is going to remind you…making yourself do it is a challenge.” Commitment levels were also a concern. P05 elaborated: “I don’t know if the commitment level would be there as much as it is when you are inside the hospital because they are actually bringing the wipes in.”

Home Management Challenges

Participants described the home environment as less structured than the hospital setting, which could make it harder to maintain a daily CHG routine. Distractions from family, pets, and household responsibilities were commonly cited. P04 explained:

…the distractions are greater at home as well because you have family, you’ve got activities, you have many pets, you may have neighbors calling. You may lose track…things come up at home. The routine is harder to keep because it’s not quite as regimented as in the hospital.

Several participants highlighted discomfort with the cold temperature of the wipes as a deterrent. P08 remarked: “You just warm them up so you are not freezing to death when you do it.” While P14 added that cold wipes would make them “…less inclined to do it,” several participants emphasized the importance of warming the wipes to encourage adherence. P01 noted logistical challenges related to warming the wipes: “It would be a challenge to keep the wipes warm.”

Self-Administration Challenges

Some participants anticipated physical difficulties with CHG self-application, particularly in reaching hard-to-access areas of the body. P06 described difficulties in “wiping your back.” While P08 echoed this and noting that fatigue or age could further impair their ability: “reaching spots on the body, if they are…older, or tired, or exhausted, or fatigued.” Several participants emphasized the need for caregiver assistance at home. P01 shared, “I would just have to make arrangements before I take a bath — who is going to be able to come over and wipe me down?”

Support Needs

Participants identified several support mechanisms they believed would promote sustained CHG adherence in the outpatient setting, including reminders and accountability, caregiver involvement, and clinical follow-up.

Reminders & accountability

Many participants emphasized the importance of reminders to ensure adherence. Suggestions included checklists, alarms, and embedding CHG into daily routines. Participants discussed how reminders and accountability would help ensure that the CHG bathing was consistently performed. P07 noted the benefit of external accountability: “…just having somebody ask if you have done it — ‘Did you do your CHG bath this day?’” P04 emphasized the need to integrate CHG into a fixed part of the day: “…find a spot in your normal routine that never changes and slip it in there somehow.”

Caregiver involvement

Participants also stressed the importance of caregiver involvement, particularly for accountability and assistance with application. P14 highlighted the benefit of caregiver training: “…on the days they do not feel like doing it themselves, they’ll have somebody who knows how to do it too.” Participants also pointed out that weakened patients might need greater reliance on caregivers during the post-discharge recovery period. P12 remarked, “…if the person is still having a lot of issues, they might need more help from someone at home.”

Clinical Follow-Up

Several participants recommended continued support from healthcare providers, such as routine check-ins or a hotline for questions. P05 suggested that nursing staff should “…ask what support do you need from us in order to make this a successful process?’” and ”…maybe having a hotline or something that they can call…” P11 proposed a follow-up protocol: “…follow-up, nursing calls, maybe weekly—’how is everything going with your CHG wipes, are you getting to do it or any signs of infection’---things like that.”

Education Needs

A final salient theme that emerged across interviews was the importance of education in promoting consistent CHG adherence. Participants emphasized the need for both understanding the purpose of CHG bathing (“the why”) and receiving clear instructions on the proper use of the wipes (“the how”).

Understanding the Purpose of CHG

Patients emphasized the importance of understanding not just how to use CHG—but why it mattered. Participants expressed that knowing the infection prevention benefits of CHG was a key motivator for adherence. Several requested that healthcare teams provide specific data or statistics to emphasize CHG’s importance. P09 suggested “…more specific statistics on what it’s preventing could help.” Similarly, P07 noted, “You don’t want to get an infection…if this wipe can prevent that, why wouldn’t you do it?”

P14 emphasized that belief in CHG’s importance would drive adherence: “…if you maybe understand what it is you’re doing, understand the why of why you are doing it, you would be more inclined to do it.”

Instruction on Proper Technique

Participants also stressed the need for thorough education on correct CHG application techniques. For example, P10 noted,“…make sure they are doing it right.” Similarly, P04 stressed the importance of not just completing the task, but doing it properly: “doing it, getting it done, getting it done properly.”

Participants advocated for re-education at key transitions in care, such as during discharge or when initiating outpatient home care. P02 suggested: “Patients need re-education when they transition home.” P03 suggested incorporating CHG training as part of home health onboarding: “When they are coming for home health care, include that with their intro or workup, showing them how to use it and what not to do.”

Participants provided practical suggestions to address common challenges and reinforce outpatient adherence, including strategies related to caregiver support, habit formation, and structured reminders, as summarized in Table 4 and Figure 1.

Table 4.

Challenges to Outpatient CHG Adherence and Suggested Support Strategies

Challenge	Suggested Support Strategy
Motivation decline	Scheduled reminders, caregiver reinforcement, and education
Home management: difficulty integrating into routine	Anchoring CHG to daily self-care activities (e.g., brushing teeth)
Home management: forgetting daily use	Phone alerts, daily checklist, nursing check-ins
Self-administration challenges	Caregiver assistance for hard-to-reach areas

Recommendations synthesized from thematic analysis of patient interviews regarding outpatient CHG use

Figure 1.

Outpatient CHG Adherence Post-HCT: Feasibility, Challenges, Support Needs, and Education Strategies

This figure summarizes major findings from patient interviews, including perceived feasibility, implementation challenges, and support needs for CHG bathing in the outpatient setting.

Discussion

Findings of this study expand on our previous work on CHG use in the in-patient setting (28) to highlight the challenges and opportunities of implementing CHG bathing in outpatient settings for HCT patients to provide further insight into outpatient-specific barriers, facilitators, and support needs. Although patients supported the feasibility and use of CHG in the outpatient setting, moving from inpatient to outpatient care fundamentally shifts the support dynamic—where patients and caregivers now take on greater responsibility for infection prevention. As our findings show, this transition isn’t just logistical; it’s psychological. Patients noted important considerations related to the added responsibility, highlighting that adherence may be more challenging without the right support. Unlike in the hospital, where nurses provide supervision and reminders, outpatient care relies on personal accountability and caregiver involvement.

Many of the barriers patients identified, such as lack of motivation and difficulty administering CHG baths independently, mirror previous inpatient research (33,34). However, as our study suggests, these challenges take on even greater significance in outpatient care, where small obstacles, like forgetting a step in the bathing process or struggling to fit it into a daily routine, may quickly become major barriers. Without structured oversight and strategies to reduce barriers, adherence may become inconsistent. This is where practical solutions come in. Patients thus recommended digital reminders, caregiver training, and scheduling tools as solutions to help make CHG bathing feel less supplementary and more like a natural part of daily life. Future outpatient protocols should also consider incorporating guidance on linen changes, as these are often included in CHG bathing protocols to reduce microbial burden in the inpatient setting, but are less formalized and lack evidence for standards in the outpatient setting.

Similar to our results related to CHG use in the in-patient setting (28), one of the strongest themes in our findings related to outpatient CHG use was the central role of medical literacy. Patients repeatedly stressed the importance of clear, straightforward guidance. They especially emphasized the importance of education regarding reasons for using CHG and its application. We, along with others, have previously reported inconsistencies in patients’ understanding of CHG bathing procedures during their inpatient stay, further highlighting the need for education and training for CHG to be successfully adopted in the outpatient setting (28,35). The use of standardized tools, such as mobile apps with step-by-step instructions and reminders, could thus provide essential structure and reinforce adherence (36). Furthermore, multifaceted programs that not only focus on patient and caregiver education, but include education and training for healthcare staff may be most effective in addressing the specific supportive needs of the patients (37). However, consistent education is not sufficient. Patients in this study emphasized the need for continued support—ongoing check-ins, re-education, and reinforcement from healthcare providers to ensure they stay on track. These small but meaningful touchpoints can significantly impact long-term adherence. Clarity on expected duration of outpatient CHG use is also essential for tailoring education and support strategies. In current inpatient protocols, CHG is typically used daily for 30 days or until neutrophil engraftment (23), aligning with the period of greatest infection risk. This 30-day window may also apply to outpatient HCT care, where patients are often seen in clinic daily. These frequent encounters create structured opportunities for nursing teams to reinforce CHG adherence and address barriers in real time.

Our findings also underscore the potential of technology in improving adherence. Mobile health apps and automated reminders not only promote consistency, but they provide a sense of accountability and structure, which many patients reported needing to stay on track (36). However, technology is not a standalone solution to care management and such tools may not be accessible for older adults or individuals with visual or cognitive impairments. For these patients, alternatives such as caregiver reminders, printed checklists, or nurse-driven adherence reinforcement during outpatient clinic visits may offer more accessible and consistent support. In addition, patients highlighted the importance of caregiver support, noting that when family members were informed and involved, they felt less alone in managing their care. Caregiver training programs could thus empower family members to take on a more active role, reinforcing infection prevention as a shared responsibility.

This study has several strengths including a focus on HCT patient perspectives and their perceived barriers and facilitators regarding the use of CHG in the outpatient setting, an area that has not been previously explored. Limitations include the recruitment of patients who were specifically in the Bone Marrow Transplant inpatient unit, which limits perspectives of recipients during other stages of treatment. In addition, we did not collect data regarding participants’ occupations. Knowledge of CHG may have varied among patients depending on their occupation and outside experiences with CHG beyond their in-patient stay. Finally, interview questions did not specifically address length of time for outpatient CHG use, thus patients’ perceptions specifically regarding duration of use was not captured in the analysis.

Conclusion

This study provides key insights into the challenges and opportunities of implementing CHG bathing in outpatient settings for HCT patients. Transitioning infection prevention from hospital to home introduces significant barriers, including lack of motivation, logistical challenges, and gaps in patient education. Without direct supervision from healthcare providers, adherence depends heavily on patient accountability, caregiver involvement, and accessible support systems. Findings from this study can inform application of CHG in the outpatient setting and development of innovative, patient-driven strategies that not only improve CHG adherence, but also advance infection prevention efforts in immunocompromised populations.

Highlights.

• HCT recipients perceived outpatient CHG bathing as feasible after discharge

• Low motivation and home routines were viewed as potential barriers to adherence

• Caregiver support and reminders were suggested to aid daily CHG bathing

• Education was highlighted as key to reinforce infection prevention and engagement

Data Availability Statement

The interview data of the present study are not publicly available due to the risk of disclosure or deduction of private individual information. However, they are available from the corresponding author upon reasonable request.